HIV/AIDS, hepatitis and sexually-transmitted infection prevention among Egyptian substance users

Doctoral thesis OPEN
Bakhoum, Atef (2015)

This thesis explores cultural influences in high-risk behaviour among Egyptian substance users in the Middle Eastern, conservative, male-dominated and predominantly Muslim society in which they live. It investigates why they practice unprotected sex despite the risk of infection by blood-borne viruses (BBVs) and sexually-transmitted infections (STIs), and the factors influencing their risk practices. The study seeks to inform policy and to improve methods of preventing BBVs/STIs among Egyptian substance users, particularly through health/sex education in peer groups and schools and through the media, civil society organisations and the criminal justice system. Data was collected via a questionnaire surveying the knowledge, attitudes and practices (KAP) of 410 substance users. Responses were compared according to the gender, age and education of the respondents and whether they took their drugs via intravenous injection. Four focus group discussions were held with twenty-four substance users, including female commercial sex workers (FCSWs), men who have sex with men (MSM), intravenous drug users (IVDUs), and people living with HIV (PLHIV), as well as in-depth interviews with fourteen policymakers. Most respondents had little or moderate knowledge about the hepatitis C and/or B viruses and little knowledge about HIV or its association with sex and drug injection. Knowledge about risky sexual behaviour connected with BBV/STI infection among substance users was low. The respondents’ attitudes and practices regarding sex and intravenous drug use indicated that they were at high risk of infection. They had negative attitudes towards PLHIV, towards each other in the substance-user population and towards other overlapping subgroups of most-at-risk populations (MARPs), i.e. FCSWs, MSM and IVDUs. Respondents with higher education and older people were found to have greater knowledge of safer sex practices. Males and IVDUs had significantly higher scores for KAP regarding IV drug use than females and non-IVDUs. The females’ KAP regarding safe sex tended to be better than that of the males. Stigma, gender and religion had a significant influence on substance use and sexual behaviour. These three factors embedded in the culture form a taboo about drugs and sex, impair substance users’ quality of life and deprive them, especially the females, of their rights, including the rights to education, employment, medical treatment, marriage and children. These factors also affect the substance users’ families, the judiciary system, healthcare institutions and society at large. HIV-related stigmatisation was greater than that for other BBVs/STIs. HIV-related stigmatisation with regard to infection via gay sex was greater than that due to heterosexual sex or IV drug use. The media potentiates the stigmatisation of substance users and PLHIV by showing negatives images of these groups, causing them to suffer strongly from public shaming, desertion, seclusion, imprisonment and unemployment. Recovery is harder for female than for male substance users due to the harsher stigmatisation. Religion plays a pivotal role in Egyptians’ lives, and most of the participants were fatalists. The participants said that they would prefer the following preventive interventions: a) sex education programmes to be introduced in drug rehabilitation programmes, police stations and prisons; b) the launch of opioid substitution therapy programmes in drug detoxification centres; c) police referral of arrested active substance users to drug detoxification and rehabilitation centres; d) a free rehabilitation service for poor and illiterate substance users; e) a greater number of wide-ranging rehabilitation programmes for MARPs.
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